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« Monday Open Thread | Is The Big Push for Midwives an Oppressive Campaign? »
Saturday
Feb052011

Comment of the Week: Understanding "Under the Radar"

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By Jill Arnold

This week’s COTW is from (one of my favorite bloggers) Rebecca Public Health Doula, left on the post Is The Big Push for Midwives an Oppressive Campaign?.

[Excerpt]

And it got me thinking about how I see the point that opponents of licensure make. I think the lawyers in the discussion made it very clear that you’re practicing just as illegally in a state with no licensure as you are practicing without a license in a state WITH licensure. But I think people have the sense that right now those CPMs in no-licensure practice “under the radar” and can offer choices to women who otherwise would have no options at all, while once licensure comes in the vast majority will choose licensure and be restricted in their offerings; and those who don’t will be more frequently targeted and easier to prosecute. Is this based in facts and past events? I have no idea. But I almost get the sense of people in the back room whispering “Shut up you guys, you’re just attracting attention and by asking for ‘legitimacy’ you’ll ruin everything.”

I believe CPM licensure is needed and important. No, licensure does not create great midwives any more than it creates great doctors, and all consumers should do their due diligence on their health care providers (and contractors, plumbers, etc.) But it creates a system for CPMs to be recognized and integrated into the system, and it sets a basic level of competency and system of redress for professional transgressions. It enables them to practice and transport without fear and for their patients to feel comfortable hiring them. But I still think it’s a fair question of whether licensure limits the options of birthing women. Do we have any evidence that it expands it, limits it, or has no effect?

 

 

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Reader Comments (21)

Can the question be rephrased as, "Does licensure mean that formerly practicing midwives will no longer offer services they offered before licensure?" I don't have any evidence, so I apologize for commenting, but I do believe you have to consider the effect of registration. Once there's a Midwifery Board and a Practice Act that they can and will be held accountable to, and once they're registered by name and address with a department of professional licensure, I imagine many midwives will be at least more uncomfortable performing "under the radar" services such as breech births or post-due births.

I think that, objectively and ideally, not licensing midwives is stupid. But in the short term, it is probably going to restrict the choices and options I and my wife immediately have, as they will now come under the scrutiny of legislators and insurance policymakers and (heaven help us) the ACOG, instead of the judgment of competent midwives. I'm not quite ready to say the sacrifice is worth it.

* did not mean to include "formerly practicing midwives", just "practicing"

Great comment! I think it really sums up the conflict. As a consumer of care, I simultaneously long for the benefits that recognition of CPMs will bring AND I dread falling outside the realm of "normal" and having my choices restricted away...

Thank you for posting the comment thread. It was fascinating and as I like to argue with myself- I could easily see both sides.

February 5, 2011 | Unregistered CommenterVanessa Manz

I read something once about the founders of this country who said (loosely) that once you enshrine the right of free speech in the constitution, you have already lost it.

I couldn't understand that for a long time. Gradually, as I started to have more experience with the law and with the gray area between "legal activities", "alegal but who cares," "illegal but no one caught me," and "being prosecuted," I understood more. Once you make a law legalizing something, it is always more limiting than the champions of the law first think. Think of "free" and "speech." Although I am not a lawyer, and I may stand corrected, my understanding is that those two terms need to be defined. And the defining is where we lose what we thought we had. For example, now the court has defined speech to include money, and speakers to include non-human persons (corporations). Suddenly "free speech" takes on a whole new meaning for a lot of people, and some view this to be limiting. (not the corporations, certainly, but probably the non-corporate humans who don't have a lot of money!)

So when it comes to licensing CPM's, I am wary, like many of the commenters. I want midwives to have the opportunity to practice without fear of prosecution. But licensing and regulating will by definition bring restrictions on their practice, and so for some, the fear of prosecution will continue (albeit for different reasons).

It is not a simple issue.

February 5, 2011 | Unregistered CommenterStacey

This comment, and the whole conversation really hits on the underlying tension in all of public health. Sometimes legitimate public health regulations like midwifery licensure conflict with, limit, or impede individual civil liberties, like a woman's right to give birth where and with whom she wants.

The devil is really in the details. In my state, recently-passed legislation did not put any practice restrictions or automatic risk-outs on a midwife's license. It would be very hard to say that this restricted women's choices. I'm curious to hear from midwives and clients in states where there are restrictions. I do understand why if the restrictions are onerous, some would feel that the trade-offs (i.e., consumer protection, better integration, ability to carry meds) aren't worth it.

February 5, 2011 | Unregistered CommenterRebecca S

"This comment, and the whole conversation really hits on the underlying tension in all of public health."

Yes. This.

February 5, 2011 | Registered CommenterJill

Most of the older midwifery licensure laws in the country pre-date the development of nationally-authorized educational and credentialing standards created by home birth midwives for home birth midwives, so each state had to make them up on their own. This is one reason why some, but not all, of the older laws are more restrictive than those that have been passed during the last 6 years, which is when midwifery advocates began to more formally organize across states via the Birth Policy yahoo group, which later gave birth to The Big Push for Midwives Campaign.

When advocates in various states began sharing model legislation, legislative strategy, messaging, resources, and best practices for building a highly mobilized and effective base of grassroots activists, it resulted in midwifery laws that strike an appropriate balance between evidence-based practice and safe standards of care. If home birth parents and their allies are mobilized, it's possible to successfully defeat attempts by opponent groups to include provisions that would result in overly restrictive regulations, such as denying access to HBAC.

February 5, 2011 | Unregistered CommenterPushGirl Friday

I think I would whole heartedly support TBP if we could get a law passed saying all women have a right to birth where they wish with whoever they wish in attendance. That would protect those who don't want to license as well as moms, yet it would give all the benifits TBP is aiming for.

We also need a law stating that one human being can not be forced to have medical procedures (including c-sections) for the health of another human being. This would give mom the ultimate power to say yes or no. No one could call CPS on her for not going along with the doctor.

February 5, 2011 | Unregistered CommenterBettySue

"...lawyers in the discussion made it very clear that you’re practicing just as illegally in a state with no licensure as you are practicing without a license in a state WITH licensure."

I'm sorry - this is not clear to me. Could you explain? I would think that if there is no law on a subject, that then there is much more freedom on it. There are no laws about where and when we eat, for a silly example. We can do that pretty much any time, anywhere, or with anyone we choose.

February 5, 2011 | Unregistered CommenterKathy

[btw, the Kathy posting just above me isn't Kathy @ Woman to Woman CBE, but another one; I did post a comment on the other post, but haven't posted on this one yet. Just didn't want some people to get confused with two people of the same name. :-)]

February 5, 2011 | Unregistered CommenterKathy
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